Free Application for Position Change or Replacement Badge.pmd - Indiana

APPLICATION FOR POSITION CHANGE OR REPLACEMENT BADGE
State Form 53543 (3-08) INDIANA GAMING COMMISSION

Casino

Name:

OR

Supplier

Name:

Occupational Licensee Identification
Last name First name Middle initial Maiden name

Address (number and street)

City

State

Zip code

Telephone number

SSN (last four digits) XXX-XX-____________

Occupational license number

Position Change
*An increase in License level requires that a new application be completed

Current position

Current department/division

Current supervisor

Current license level*

New position

New department/division

New supervisor

New license level*

Effective date (month, day, year) Was the old IGC badge collected? Yes No

Human Resources authorization Signature: Date:

Reinstatement
*A license may be reinstated only if the applicant returns to the same employer within 60 days following separation of service

New position

New department/division

New supervisor

New license level

Reinstatement date* (month, day, year)

Human Resources authorization Signature: Date:

Lost/Damaged Badge or Name Change

Lost
New last name (if applicable)

Stolen

Damaged

Name Change
New middle initial New maiden name (if applicable)

New first name (if applicable)

Signatures
All costs in connection with the issuing of this IGC Badge will be billed to the Casino or Supplier. Any reimbursement on the part of the Applicant is the responsibility of the Casino or Supplier. The Applicant has been made aware that making a false statement on this application will be grounds for the revocation of same. All necessary steps have been taken to surrender previously issued IGC badge.

Signature of Applicant

Date (month, day, year)

Name of IGC Agent

Identification number

Date (month, day, year)